Healthcare Provider Details

I. General information

NPI: 1710049218
Provider Name (Legal Business Name): LA FAMILIA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 CAJA DEL ORO GRANT RD
SANTA FE NM
87507-3279
US

IV. Provider business mailing address

2145 CAJA DEL ORO GRANT RD
SANTA FE NM
87507-3279
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-3195
  • Fax: 505-982-6280
Mailing address:
  • Phone: 505-982-4415
  • Fax: 505-982-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number321876
License Number StateNM

VIII. Authorized Official

Name: BRANDON VANESSA VAN PELT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 505-982-4425